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Sa1592 Long-Term Outcomes of Colorectal ESD in a Western Tertiary Referral Centre.
Abstracts
Sa1592 Long-Term Outcomes of Colorectal ESD in a Western Tertiary Referral Centre. Christophe Snauwaert*, Hubert Piessevaux Hepatology and Gastroenterology, Cliniques Universitaires Saint Luc, Brussels, Belgium Introduction: Colorectal endoscopic submucosal dissection (CR-ESD) enables enbloc resection of lesions O2 cm which would otherwise require piecemeal removal. However, CR-ESD is still considered as technically challenging and is not widespread outside Asian expert centres. Aim: To assess efficacy and safety of CRESD and identify possible risk factors for technical difficulty. Methods: Analysis of charts from 173 consecutive patients treated by CR-ESD between May 2006 and July 2013. Efficacy and safety endpoints were complete en-bloc resection rate, mucosal recurrence rates and complications. Results: Median age of patients was 67 years (IQR 58-76). Lesions were located throughout the colon with caecal and rectal predominance (Table 1). Median longest and perpendicular diameter of lesions was 35mm (range 10-150mm) and 30mm (range 8-130mm) respectively. Most lesions were classified as Paris 0-IIa (45.1%), 0-Is (29.5%) and 0-IIb (17.3%). Forty-eight percent of lesions were classified as LST-NG according to the Japanese classification. In 15.6% of cases a previous resection had been attempted elsewhere. Full ESD was performed in 117 (68%) patients; the remainder was treated using a hybrid technique of circumferential submucosal incision, dissection and finally followed by enbloc snare resection. Median procedure time was 109 minutes (IQR 70-157). The enbloc resection rate was 74.6% (129/173). Previous attempt at resection was a risk factor for en-bloc resection failure (40.8% vs. 22.7%; p!0.05). Twenty-one (12.1%) perforations occurred during ESD, which were all successfully managed by endoscopic clip closure. Post-procedure complications occurred in 46 patients (26.9%) of which 15 delayed perforations (8.6%). The complication rate decreased significantly with growing experience (e.g. 14 delayed perforations for the first 87 cases vs. 1 for the last 86 cases; 16% vs. 1%; p!0.05). Two patients required surgery for postprocedural perforation salvage. Median hospital stay was 2 days (IQR 2-2). The majority of lesions (114/173; 65%) contained high-grade dysplasia or more advanced histopathology (Table 2). Free vertical margins were achieved in 92% (160/173) of patients. Fourteen patients underwent additional surgical resection because of incomplete resection or unfavourable histology. Endoscopic follow-up was available in 147 patients. During the median follow-up period of 13 months (IQR 3-24), 1 mucosal recurrence occurred (0.7%). Conclusion: CR-ESD is very effective with low local recurrence rates. Previous resection attempts are significantly predictive for enbloc resection failure. Postprocedural course is favourable with short hospitalisation stays. Complications (e.g. delayed perforations) have to be considered but usually can be managed conservatively. A higher level of experience significantly reduces the post-procedural complication rate.
Sa1593 Risk of Lymph Node Metastasis in Colorectal Submucosal Invasive Cancer: Clinicopathological Differences Between Colonic and Rectal Lesion Masayoshi Yamada*1, Taku Sakamoto1, Takeshi Nakajima1, Hirokazu Taniguchi2, Shigeki Sekine3, Yukihide Kanemitsu4, Takahisa Matsuda1, Yutaka Saito1 1 Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; 2 Pathology and Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, Japan; 3Molecular Pathology Division, National Cancer Center Research Institute, Tokyo, Japan; 4Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan Background: Less invasive treatment for colorectal cancer is now available. Predicting lymph node metastasis (LNM) is particularly important in the decision of treatment for colorectal submucosal invasive cancers (pT1). Predictors for LNM have been reported in pT1 colorectal cancer. However, whether there are any biological differences between colonic and rectal cancers is uncertain. Methods: To clearly demonstrate clinicopathological differences between colonic and rectal pT1 cancer, a retrospective cross-sectional study was performed in a total of 1098 colorectal pT1 cancers that were resected between December 1993 and December 2011 in National Cancer Center Hospital, Tokyo, Japan. This sample included 249 cases of endoscopic resection (ER), 175 of ER with additional surgical resection (ER+OP) and 674 of surgical resection (OP).1) In a total of 849 cases of the ER+OP and OP group, risk factors for LNM were analyzed. 2) In a total of 1098 cases, a comparison between tumor location and clinicopathological features such as age, gender, tumor size, macroscopic type, growth type (polypoid/ non-polypoid), histological type (well differentiated adenocarcinoma/ others), depth of invasion [!1000mm (T1a)/ R1000mm (T1b)], presence/ absence of lymphovascular (ly/v) invasion, recurrence and LNM was made. Tumor location was divided as follows: right-sided colon (cecum transverse colon), left-sided colon (descending rectosigmoid colon) and rectum (Ra/b) group. Based on Japanese Classification of Colorectal Carcinoma, the depth of SM invasion was measured from the lower muscularis mucosae to deepest area of invasion or from the surface of the tumor if the muscularis mucosae was difficult to identify. Results: 1) LNM was detected in 12.8% (109/849) of EP+OP and OP cases. Univariate analysis revealed that T1b, ly/v invasion and histological type of other than well differentiated adenocarcinoma was significantly more likely to be associated with LNM positive group. Multivariate analysis revealed that ly/v invasion [odds ratio 3.3 (95% confidence interval: 2.1 - 5.2)] was a risk factor for LNM in this sample. 2) Although there was no statistical difference in LNM, ly/v invasion was significantly higher in rectum than in the right- and left-sided colon (34% vs 21% and 22%). In the stratified analysis, ly/v invasion was significant higher in T1b of rectum than right- and left-sided colon. Rectum group had the lowest recurrence free survival curve compare to the rightand left-sided colon groups (log-rank test, P!0.05, respectively). Conclusion: The present
Table 1 Location Ileo-caecal valve Caecum Ascending colon Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon Rectum Ileo-anal pouch
Number (Total [ 173)
Percentage
8 37 20 12 7 4 3 11 69 2
4.6% 21.4% 11.6% 6.9% 4% 2.3% 1.7% 6.4% 39.9% 1.2%
Table 2 Histopathology No dysplasia Low-grade dysplasia High-grade dysplasia T1m2 T1m3 T1sm1 T1sm2 T1sm3 T2 Unknown
Number (Total [ 173)
Percentage
12 45 62 31 3 12 4 1 1 2
7% 26% 35.8% 17.9% 1.7% 6.9% 2.3% 0.6% 0.6% 1.2%
AB274 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
www.giejournal.org
Sa1592 Long-Term Outcomes of Colorectal ESD in a Western Tertiary Referral Centre. Christophe Snauwaert*, Hubert Piessevaux Hepatology and Gastroenterology, Cliniques Universitaires Saint Luc, Brussels, Belgium Introduction: Colorectal endoscopic submucosal dissection (CR-ESD) enables enbloc resection of lesions O2 cm which would otherwise require piecemeal removal. However, CR-ESD is still considered as technically challenging and is not widespread outside Asian expert centres. Aim: To assess efficacy and safety of CRESD and identify possible risk factors for technical difficulty. Methods: Analysis of charts from 173 consecutive patients treated by CR-ESD between May 2006 and July 2013. Efficacy and safety endpoints were complete en-bloc resection rate, mucosal recurrence rates and complications. Results: Median age of patients was 67 years (IQR 58-76). Lesions were located throughout the colon with caecal and rectal predominance (Table 1). Median longest and perpendicular diameter of lesions was 35mm (range 10-150mm) and 30mm (range 8-130mm) respectively. Most lesions were classified as Paris 0-IIa (45.1%), 0-Is (29.5%) and 0-IIb (17.3%). Forty-eight percent of lesions were classified as LST-NG according to the Japanese classification. In 15.6% of cases a previous resection had been attempted elsewhere. Full ESD was performed in 117 (68%) patients; the remainder was treated using a hybrid technique of circumferential submucosal incision, dissection and finally followed by enbloc snare resection. Median procedure time was 109 minutes (IQR 70-157). The enbloc resection rate was 74.6% (129/173). Previous attempt at resection was a risk factor for en-bloc resection failure (40.8% vs. 22.7%; p!0.05). Twenty-one (12.1%) perforations occurred during ESD, which were all successfully managed by endoscopic clip closure. Post-procedure complications occurred in 46 patients (26.9%) of which 15 delayed perforations (8.6%). The complication rate decreased significantly with growing experience (e.g. 14 delayed perforations for the first 87 cases vs. 1 for the last 86 cases; 16% vs. 1%; p!0.05). Two patients required surgery for postprocedural perforation salvage. Median hospital stay was 2 days (IQR 2-2). The majority of lesions (114/173; 65%) contained high-grade dysplasia or more advanced histopathology (Table 2). Free vertical margins were achieved in 92% (160/173) of patients. Fourteen patients underwent additional surgical resection because of incomplete resection or unfavourable histology. Endoscopic follow-up was available in 147 patients. During the median follow-up period of 13 months (IQR 3-24), 1 mucosal recurrence occurred (0.7%). Conclusion: CR-ESD is very effective with low local recurrence rates. Previous resection attempts are significantly predictive for enbloc resection failure. Postprocedural course is favourable with short hospitalisation stays. Complications (e.g. delayed perforations) have to be considered but usually can be managed conservatively. A higher level of experience significantly reduces the post-procedural complication rate.
Sa1593 Risk of Lymph Node Metastasis in Colorectal Submucosal Invasive Cancer: Clinicopathological Differences Between Colonic and Rectal Lesion Masayoshi Yamada*1, Taku Sakamoto1, Takeshi Nakajima1, Hirokazu Taniguchi2, Shigeki Sekine3, Yukihide Kanemitsu4, Takahisa Matsuda1, Yutaka Saito1 1 Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; 2 Pathology and Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, Japan; 3Molecular Pathology Division, National Cancer Center Research Institute, Tokyo, Japan; 4Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan Background: Less invasive treatment for colorectal cancer is now available. Predicting lymph node metastasis (LNM) is particularly important in the decision of treatment for colorectal submucosal invasive cancers (pT1). Predictors for LNM have been reported in pT1 colorectal cancer. However, whether there are any biological differences between colonic and rectal cancers is uncertain. Methods: To clearly demonstrate clinicopathological differences between colonic and rectal pT1 cancer, a retrospective cross-sectional study was performed in a total of 1098 colorectal pT1 cancers that were resected between December 1993 and December 2011 in National Cancer Center Hospital, Tokyo, Japan. This sample included 249 cases of endoscopic resection (ER), 175 of ER with additional surgical resection (ER+OP) and 674 of surgical resection (OP).1) In a total of 849 cases of the ER+OP and OP group, risk factors for LNM were analyzed. 2) In a total of 1098 cases, a comparison between tumor location and clinicopathological features such as age, gender, tumor size, macroscopic type, growth type (polypoid/ non-polypoid), histological type (well differentiated adenocarcinoma/ others), depth of invasion [!1000mm (T1a)/ R1000mm (T1b)], presence/ absence of lymphovascular (ly/v) invasion, recurrence and LNM was made. Tumor location was divided as follows: right-sided colon (cecum transverse colon), left-sided colon (descending rectosigmoid colon) and rectum (Ra/b) group. Based on Japanese Classification of Colorectal Carcinoma, the depth of SM invasion was measured from the lower muscularis mucosae to deepest area of invasion or from the surface of the tumor if the muscularis mucosae was difficult to identify. Results: 1) LNM was detected in 12.8% (109/849) of EP+OP and OP cases. Univariate analysis revealed that T1b, ly/v invasion and histological type of other than well differentiated adenocarcinoma was significantly more likely to be associated with LNM positive group. Multivariate analysis revealed that ly/v invasion [odds ratio 3.3 (95% confidence interval: 2.1 - 5.2)] was a risk factor for LNM in this sample. 2) Although there was no statistical difference in LNM, ly/v invasion was significantly higher in rectum than in the right- and left-sided colon (34% vs 21% and 22%). In the stratified analysis, ly/v invasion was significant higher in T1b of rectum than right- and left-sided colon. Rectum group had the lowest recurrence free survival curve compare to the rightand left-sided colon groups (log-rank test, P!0.05, respectively). Conclusion: The present
Table 1 Location Ileo-caecal valve Caecum Ascending colon Hepatic flexure Transverse colon Splenic flexure Descending colon Sigmoid colon Rectum Ileo-anal pouch
Number (Total [ 173)
Percentage
8 37 20 12 7 4 3 11 69 2
4.6% 21.4% 11.6% 6.9% 4% 2.3% 1.7% 6.4% 39.9% 1.2%
Table 2 Histopathology No dysplasia Low-grade dysplasia High-grade dysplasia T1m2 T1m3 T1sm1 T1sm2 T1sm3 T2 Unknown
Number (Total [ 173)
Percentage
12 45 62 31 3 12 4 1 1 2
7% 26% 35.8% 17.9% 1.7% 6.9% 2.3% 0.6% 0.6% 1.2%
AB274 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
www.giejournal.org